Nursing Elites

1. What foods are appropriate for a 30-month-old toddler on a regular diet?

• A. Hamburger with bun and grapes
• B. Chicken fingers and french fries
• C. Hot dog with bun and potato chips
• D. Macaroni and cheese and Cheerios

Correct answer: D

Rationale: Macaroni and cheese and Cheerios are appropriate choices for a 30-month-old toddler on a regular diet. These foods are easy to chew, digest, and are generally well-liked by toddlers. Option A, a hamburger with bun and grapes, may be difficult for a toddler to handle due to the size of the hamburger and grapes pose a choking hazard. Option B, chicken fingers and french fries, may be too greasy and processed for a toddler's developing digestive system. Option C, hot dog with bun and potato chips, is also not ideal as hot dogs can be a choking hazard and potato chips are high in salt and may not provide adequate nutrition.

2. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the health care provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL to prevent overdistension and potential harm. Choice A (100 to 150 mL) is too low and may not be effective in achieving the desired outcome. Choices C (255 to 360 mL) and D (365 to 500 mL) exceed the safe range for a 2-year-old child and can lead to overdistension, electrolyte imbalance, or other complications. Therefore, the correct answer is B.

3. A newborn is admitted to the neonatal intensive care unit (NICU) with choanal atresia. Which part of the infant’s body should the nurse assess?

• A. Rectum
• B. Nasopharynx
• C. Intestinal tract
• D. Laryngopharynx

Correct answer: B

Rationale: Choanal atresia is a congenital condition that presents with a blockage in the nasal passages at the junction of the nasal cavity and the nasopharynx. To assess and confirm the diagnosis of choanal atresia, the nurse should focus on assessing the nasopharynx. Choices A, C, and D are incorrect as choanal atresia specifically involves a blockage in the nasal passages, not the rectum, intestinal tract, or laryngopharynx. By assessing the nasopharynx, the severity of the obstruction can be determined, aiding in planning appropriate interventions for the newborn.

4. The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury?

• A. Recommend raising the bed's side rails throughout the day and night.
• B. Suggest having a caregiver present continuously to prevent falls from bed.
• C. Encourage the use of a loose restraint when he is in bed.
• D. Recommend raising the bed's side rails when a caregiver is not present.

Correct answer: D

Rationale: For a child with muscular dystrophy who fell out of bed, it is important to prevent further injuries. Using bed side rails when a caregiver is not present can help provide a safety measure and prevent falls. While continuous caregiver presence (choice B) may be ideal, it may not always be feasible. Recommending raising the bed's side rails throughout the day and night (choice A) may limit the child's mobility unnecessarily. Encouraging the use of a loose restraint (choice C) can be dangerous and may increase the risk of injury in case of a fall.

5. A child with acute lymphoblastic leukemia (ALL) is hospitalized for treatment. What is the priority nursing intervention?

• A. Administering antibiotics
• B. Preventing infection
• C. Providing nutritional support
• D. Managing pain

Correct answer: B

Rationale: The priority nursing intervention for a child hospitalized for acute lymphoblastic leukemia (ALL) is preventing infection. Children with ALL have compromised immune systems, making them highly vulnerable to infections. Preventing infections through strict aseptic techniques, isolation precautions, and proper hygiene is crucial to safeguard the child's health. Administering antibiotics (choice A) may be necessary if an infection occurs, but the primary focus should be on infection prevention. While providing nutritional support (choice C) is important, preventing infection takes precedence due to its direct impact on the child's survival. Managing pain (choice D) is essential for the child's comfort but is not the priority over preventing life-threatening infections in this scenario.

Similar Questions